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Register Online

Thank you for choosing to register online. You may enter your information into the form below and submit it electronically to our office. The information is strictly confidential and is only seen by the doctor and medical office staff. Or you may print this page, enter the information by hand and bring it with you to the office.

 

Patient Information

 

Date: 

First Name:    Middle:     Last Name:

Home Address:

City:   State Zip

Home Phone: Date of Birth: Age:

SS#:  Marital Status:

Occupation: Employer:

Business Address:
City: State: Zip Code:
Business Phone:

Spouse or Nearest Relative: Phone:

Email      


Primary Insurance

Name of Insured:

Relationship:

ID#:

Employer:

Ins. Company:

Group #:


Secondary Insurance

Name of Insured:

Relationship:

ID#:

Employer:

Ins. Company:

Group #:

 

Send Reports to Doctor:

Address:

**Referred By:

Address:

This signature will act as a "signature on file" and will remain active for all claims.  When you arrive at the office, we will ask that you sign below. 

Signature:________________________________ Date:_____________________

 

 

Health Questionnaire

Please take the time to answer the following questions:

Height: Weight:

What symptoms or concerns made you seek a consultation?

Do you have any medical problems? (Example: High Blood Pressure, Asthma, Heart disease, Previous heart attack, Diabetes, Arthritis etc.)
No medical problems

What previous operations have you had and when were they?
   No surgery

Please list the medications to which you are allergic:
No allergies

 

Please list the name, dosages and frequency of your medications:
No Medications

 

 

Do you have a problem with:

Nasal Congestion Sinus Pain/Pressure Runny Nose Sneezing Headache
Hoarseness Swallowing Throat pain Throat infections Ear Infections
Hearing Loss Ringing Ears Draining Ears Ear Pain Dizziness
Snoring Chest Pain Difficulty Breathing Itchy eyes Heartburn

 

 

Please check if any of the following apply to you:

A mole that has enlarged or changed shape or color Nasal Injuries Wide or disfigured scars Eye problems Facial Operations
Eyeglasses or contact lenses Spider veins Excessive sun exposure or sunburns Nasal Operations Bleed or bruise easily
Sinusitis, loss of smell or taste Forehead wrinkles/frown lines Squint wrinkles / lines ( around eyes) TMJ problems Weight loss
Loss of appetite Skin blemishes Acne Abnormal wound healing; keloids Neck surery

Please check all medical or surgical conditions you or members
 of your family have now or have had in the past:

Disorder

You

Family
Heart disease, murmurs 

Rheumatic fever
High or low blood pressure
High cholesterol, triglyceride
Stomach or ulcer disease
Liver, spleen disease
Jaundice, hepatitis 

Kidney or bladder disease 
HIV risk, AIDS  
Gynecologic disorders
Diabetes, thyroid, endocrine disease

Disorder

You

Family
Blood or lymph gland disorders
Tumors, growths, cysts
Muscle, bone or joint disorders

Nervous system disorders 
Psychological disorders 
Alcohol or drug problems 
Cancer, skin cancer 
Strokes, migraines, seizures 
Anesthetic reactions 
Bleeding problems, anemia
 Blood transfusion 

 

Do you smoke?   How many packs?  
For how many years? 

Do you drink alcohol? How many drinks per week?
For how many years? 

 

Thank you for taking the time to register online.  Your information is strictly confidential and  will be directed to your private chart.  We recommend that you print a copy of this completed form for your files.  

Please 

  1. Review your  information
  2. Print the form by pressing the print button on your browser, then
  3. Press the submit button below to send it electronically to our office.

 Thank you.

                                                   

 
 
 
 
Philip J. Miller, M.D.
Assistant Professor, Department of Otolaryngology
New York University School of Medicine
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